Spinal cord compression occurs in approximately 5% of patients with cancer (approximately 80 000 patients per year), mostly prostate, breast, or lung cancer. In 20% of patients, SCC precedes the cancer diagnosis, especially in patients with lung cancer.1The tumor usually reaches the vertebral body via arterial embolization but may also spread by the Batson plexus. Extension of paravertebral tumor through the neural foramina may compress the cord without vertebral involvement. Rarely, tumor spreads directly to the epidural space itself.2In keeping with relative size and blood flow, metastases to the thoracic cord are most common, followed by the lumbar and cervical regions.2Symptom onset may be gradual in the case of a slowly expanding mass or rapid in the case of a vertebral fracture with herniation of bone or disc elements into the epidural space. The resulting SCC causes initially reversible edema followed by eventually irreversible vascular occlusion, lending urgency to the evaluation.3Back pain is the presenting symptom in more than 80% of patients.4,5Weakness is present in 35% to 75% of patients at diagnosis, with one-half unable to walk.4Functional status at diagnosis is the strongest prognostic factor, with inability to ambulate or sphincter dysfunction suggesting poor neurologic outcomes.3,4Urgent evaluation of new or worsening back pain or any other neurologic symptom is essential in any patient with cancer. Magnetic resonance imaging (MRI) of the entire spine is the initial study of choice with greater than 93% sensitivity and specificity (Figure 1).6One-third of patients have multiple sites of compression at initial diagnosis.1,5,6Treatment with high-dose corticosteroids should be initiated urgently in patients with neurologic dysfunction as they may reduce edema and preserve neurologic function until definitive therapy can be performed. One randomized trial7showed a benefit of dexamethasone, 96 mg, given intravenously prior to radiosurgery; however, the optimal dose, route, and schedule remain unclear.7- 9Most experts advocate higher doses of dexamethasone in patients with rapidly worsening weakness or autonomic dysfunction. Steroids should be followed by definitive treatment with radiotherapy or surgery as soon as possible.4,10A large randomized trial11showed the benefit of surgery prior to radiotherapy for ambulation, continence, and survival in patients with solitary compressive sites by radioresistant tumors. These results may not apply to all patients because those with recurrent SCC, symptoms lasting longer than 48 hours, multiple sites of compression, cauda equina lesions, radiosensitive tumors, symptomatic brain lesions, or high surgical risk were excluded.11Unfortunately, this means that a substantial proportion of patients with SCC would have been excluded from this trial. Therefore, the decision of whether to treat with radiation or surgery first remains a clinical one. Neurosurgical intervention prior to radiotherapy is indicated in patients with rapidly evolving neurologic deficits from vertebral bone compression, as opposed to soft-tissue tumor, and with mechanical instability (indicated by pain provoked by positional changes). Radiotherapy should be considered after surgical treatment or in patients who are not surgical candidates. While no randomized controlled trials have directly compared radiotherapy with placebo, radiotherapy clearly benefits most patients by resulting in improved pain and functional ability.4,10,11Newer techniques of image-guided intensity-modulated radiotherapy allow higher doses to be precisely delivered to tumor with less spinal cord exposure and have been shown to provide long-lasting local tumor control and symptom relief with minimal toxic effects.12,13Image-guided intensity-modulated radiotherapy also allows for re-treatment of recurrent lesions and may permit prevention or delay of surgery in both radiosensitive tumors as well as those thought traditionally to be radioresistant.12,13Chemotherapy also improves symptoms and survival for chemosensitive tumors such as lymphoma and breast cancer.14,15Given the consequences of SCC, prevention would be ideal. Bisphosphonates have been shown to decrease the incidence of vertebral metastases and fracture but not SCC, although a meta-analysis found a trend for decreased incidence of SCC.16- 18The effects of calcium and vitamin D remain unstudied, but they are commonly prescribed.